<html>

<head>

<title>WallyPark Secure Membership Form</title>

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<body bgcolor="#FFFFFF" text="#000000" leftmargin="10" topmargin="0" onLoad="placeFocus()">



<form name="user" action="store.php" method="post" onSubmit="return validation(this)">

  <table width="320" border="0" cellspacing="0" cellpadding="0">

    <!--DWLayoutTable-->

    

    <tr>

      <td colspan="4" rowspan="3" valign="top">



        <div align="left"><img src="wally_logo.gif" width="150" height="15"></div></td>

      <td width="62" height="10"></td>

    </tr>

    <tr>

      <td height="3"></td>

    </tr>

    <tr>

      <td height="6"></td>

    </tr>

    <tr>

      <td colspan="5" valign="top"><font size="2"><strong>WallyPark</strong><br>



        9700 Bellanca Avenue<br>

      Los Angeles, CA 90045<br>

      <a href="mailto:marketing@wallypark.com"><font color="#666666">marketing@wallypark.com </font></a><br>

      </font>

        <hr>

        <font size="2">&nbsp;        </font></td>

    </tr>

    

    <tr>



      <td colspan="5" valign="top"><div align="left"><span class="style13 style11 style5 style2">*</span><span class="style16"> Required Field <br>

      </span>

          <hr>

      <span class="style16">          </span></div></td>

    </tr>



    <tr>

      <td width="94" valign="top"><font size="2">Name<span class="style5">*</span></font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="name" size="35" tabindex="1">



      </font></td>

    </tr>

    

    <tr>

      <td valign="top"><font size="2">Company </font></td>

      <td colspan="4" valign="top"> <font size="2"> 

      <input type="text" name="company" size="35" tabindex="2">

      </font></td>

    </tr>

    

    <tr>

      <td valign="top"><font size="2">Address<span class="style5">*</span></font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="address" size="35" value="" tabindex="3">

      </font></td>

    </tr>

    

    <tr>

      <td valign="top"><font size="2">City<span class="style5">*</span></font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="city" size="20" tabindex="4">



      </font></td>

    </tr>

    

    <tr>

      <td valign="top"><font size="2">State<span class="style5">*</span></font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="state" size="20" tabindex="5">



      </font></td>

    </tr>

    

    <tr>

      <td valign="top"><font size="2">Zip<span class="style5">*</span></font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="zip" size="20" tabindex="6">



      </font></td>

    </tr>

    

    <tr>

      <td height="22" valign="top"><font size="2">Phone<span class="style5">*</span> </font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="phone" tabindex="7">

      </font></td>

    </tr>

    <tr>

      <td valign="top"><font size="2">Fax</font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="fax" tabindex="8">

      </font></td>

    </tr>

    

    <tr>



      <td height="22" valign="top"><font size="2">E-mail<span class="style4">*</span></font></td>

      <td colspan="4" valign="top"> <font size="2"> 

        <input type="text" name="email" tabindex="9">

      </font></td>

    </tr>

    <tr>

      <td colspan="3" valign="top"><font size="2">Membership Options</font></td>

      <td colspan="2" valign="top"><font size="2"> 

        <select name="s11" tabindex="10">

          <option value="1 Year $25.00" selected><font size="2">1 Year $25.00</font></option>



          <option value="2 Years $35.00"><font size="2">2 Years $35.00</font></option>

          <option value="3 Years $50.00"><font size="2">3 Years $50.00</font></option>

        </select>

      </font></td>

    </tr>

    

    <tr>

      <td height="22" colspan="3" valign="top"><font size="2">Promo Code<span class="style2">(FREE 1 yr membership)</span></font></td>



      <td colspan="2" valign="top"><font size="2"> 

        

        <input type="text" name="procode" tabindex="11">

      </font></td>

    </tr>

    <tr>

      <td height="24" colspan="2" valign="top"><font size="-1">Credit Card Type<strong><span class="style5">*</span></strong></font></td>



      <td colspan="3" valign="top"><font size="2"> 

      <select name="s12" tabindex="12">

        <option value="None" selected><font size="2">None</font></option>

        <option value="Visa"><font size="2">Visa</font></option>

        <option value="MasterCard"><font size="2">MasterCard</font></option>

        <option value="American Express"><font size="2">American Express</font></option>

        <option value="Discover"><font size="2">Discover</font></option>



        <option value="Diners Club"><font size="2">Diners Club</font></option>

      </select>

      </font></td>

    </tr>

    

    <tr>

      <td height="22" colspan="2" valign="top"><font size="2">Credit Card Number<span class="style5"><strong>*</strong></span></font></td>

      <td colspan="3" valign="top"><font size="2"> 

        <input name="ccno1" type="text" id="ccno1" size="25">



      </font></td>

    </tr>

    <tr>

      <td height="24" colspan="2" valign="top"><font size="2">Expiration Date<span class="style5"><strong>*</strong></span></font></td>



      <td colspan="3" valign="top"><font size="2"> 

        <select name="edmon" tabindex="17">

          <option value="None" selected><font size="2">Month</font><font size="2"></font></option>

          <option value="01"><font size="2">01</font><font size="2"></font></option>

          <option value="02"><font size="2">02</font><font size="2"></font></option>

          <option value="03"><font size="2">03</font><font size="2"></font></option>

          <option value="04"><font size="2">04</font><font size="2"></font></option>



          <option value="05"><font size="2">05</font><font size="2"></font></option>

          <option value="06"><font size="2">06</font><font size="2"></font></option>

          <option value="07"><font size="2">07</font><font size="2"></font></option>

          <option value="08"><font size="2">08</font><font size="2"></font></option>

          <option value="09"><font size="2">09</font><font size="2"></font></option>

          <option value="10"><font size="2">10</font><font size="2"></font></option>



          <option value="11"><font size="2">11</font><font size="2"></font></option>

          <option value="12"><font size="2">12</font><font size="2"></font></option>

        </select>

        <select name="edyear" tabindex="18">

          <option value="None" selected><font size="2">Year</font></option>

          <option value="2005"><font size="2">2005</font></option>

          <option value="2006"><font size="2">2006</font></option>



          <option value="2007"><font size="2">2007</font></option>

          <option value="2008"><font size="2">2008</font></option>

          <option value="2009"><font size="2">2009</font></option>

          <option value="2010"><font size="2">2010</font></option>

        </select>

      </font></td>

    </tr>

    

    <tr>

      <td height="4" colspan="5"></td>

    </tr>

    <tr>

      <td height="4" colspan="5"><font size="2">Would you like Express Checkout? 

        <input type="radio" name="r1" value="Yes" checked tabindex="19">

        Yes 

        <input type="radio" name="r1" value="No" tabindex="20">

      No </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Would you like the above credit card to be 

        used for Express Checkout? 

        <input type="radio" name="r2" value="Yes" checked tabindex="21">

        Yes 

        <input type="radio" name="r2" value="No" tabindex="22">

      No</font></td>

    </tr>

    <tr>

      <td height="4" colspan="5"></td>

    </tr>

    <tr>

      <td height="4" colspan="5"><em><strong>If not, please specify which credit

      card you would like to use:</strong></em></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Express Checkout Credit Card

          Type</font><font size="2">

      <select name="select" tabindex="23">

        <option value="None" selected>None</option>

        <option value="Visa">Visa</option>

        <option value="MasterCard">MasterCard</option>

        <option value="American Express">American Express</option>

        <option value="Discover">Discover</option>

        <option value="Diners Club">Diners Club</option>

      </select>

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Express Checkout Credit Card

          Number</font><font size="2">

      <input name="ccno2" type="text" id="ccno2" size="25">

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Express Checkout Expiration Date</font><font size="2">

      <select name="s22" tabindex="28">

        <option value="None" selected>Month</option>

        <option value="01">01</option>

        <option value="02">02</option>

        <option value="03">03</option>

        <option value="04">04</option>

        <option value="05">05</option>

        <option value="06">06</option>

        <option value="07">07</option>

        <option value="08">08</option>

        <option value="09">09</option>

        <option value="10">10</option>

        <option value="11">11</option>

        <option value="12">12</option>

      </select>

      <select name="s23" tabindex="29">

        <option value="None" selected>Year</option>

        <option value="2005">2005</option>

        <option value="2006">2006</option>

        <option value="2007">2007</option>

        <option value="2008">2008</option>

        <option value="2009">2009</option>

        <option value="2010">2010</option>

      </select>

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">FREE family memberships (add

      up to 3 members, membership cards only):</font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">1.&nbsp;

          <input type="text" name="fmem1" size="25" tabindex="30">

&nbsp;</font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">2.&nbsp;

          <input type="text" name="fmem2" size="25" tabindex="31">

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">3.&nbsp;

          <input type="text" name="fmem3" size="25" tabindex="32">

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Use the same credit card for

          above family member on file for express checkout?<br>

        <input type="radio" name="r3" value="Yes" checked tabindex="33">

Yes

<input type="radio" name="r3" value="No" tabindex="34">

No </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2"><strong>If yes, you authorize

            WallyPark to charge parking and services to the credit card on file

      to the family members listed above.</strong></font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2"><em><strong>If not, please provide

      an alternate credit card number.</strong></em></font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Family Member Express Checkout

          Credit Card Type:</font><font size="2">

      <select name="s31" tabindex="35">

        <option value="None" selected>None</option>

        <option value="Visa">Visa</option>

        <option value="MasterCard">MasterCard</option>

        <option value="American Express">American Express</option>

        <option value="Discover">Discover</option>

        <option value="Diners Club">Diners Club</option>

      </select>

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Family Member Express Checkout

          Credit Card Number: </font><font size="2">

      <input name="ccno3" type="text" id="ccno3" size="25">

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><font size="2">Family Member Express Checkout

          Expiration Date:</font><font size="2">

      <select name="s32" tabindex="40">

        <option value="None" selected>Month</option>

        <option value="01">01</option>

        <option value="02">02</option>

        <option value="03">03</option>

        <option value="04">04</option>

        <option value="05">05</option>

        <option value="06">06</option>

        <option value="07">07</option>

        <option value="08">08</option>

        <option value="09">09</option>

        <option value="10">10</option>

        <option value="11">11</option>

        <option value="12">12</option>

      </select>

      <select name="s33" tabindex="41">

        <option value="None" selected>Year</option>

        <option value="2005">2005</option>

        <option value="2006">2006</option>

        <option value="2007">2007</option>

        <option value="2008">2008</option>

        <option value="2009">2009</option>

        <option value="2010">2010</option>

      </select>

      </font></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><span class="style3">Date of next stay at WallyPark</span>

        <input name="nst" type="text" id="nst" size="12" maxlength="10" tabindex="42"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><span class="style3">Additional Notes:(Optional)</span>

        <input name="option" type="text" tabindex="43" value="" size="35"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"></td>

    </tr>

    <tr>

      <td height="8" colspan="5"><input type="submit" name="s1" value="Submit" tabindex="44">

OR

  <input type="reset" name="Submit2" value="Reset" tabindex="45"></td>

    </tr>

    <tr>

      <td></td>

      <td width="51"></td>

      <td width="39"></td>

      <td width="86"></td>

      <td></td>

    </tr>

  </table>

</form>

</body>

</html>

